[Surgical treatment of gallbladder diseases in patients over 70 years of age]

The authors give a retrospective analysis of the results of 162 biliary operations performed in a five-year period on patients over 70 years of age. The mortality rate of 87 elective operations was 3.45%, of 75 acute operations 6.17%. During the same period 321 ERCPs and 120 ESTs were carried out in patients over 70, out of whom 2 were operated on and lost (mortality: 1.67%) because of bleeding after EST. The total mortality rate was 7.41% (n = 12). The circumstances of negative and positive choledochotomies were analysed together with the relationship between the operating time and the course of the disease. Out of the negative choledochotomised patients (n = 10) 3, out of the positive ones (n = 40) 5 patients died. For each patient over 70, to shorten the operative time and to prevent perioperative complications, the authors recommend the consideration of ERCP prior to biliary operation, and in certain cases, instead of elective biliary surgery, for bile duct stone, EST and stone extraction is advisable, leaving the calculous gallbladder "in situ". Further investigations are necessary, in the authors opinion, to decide whether prior to emergency operation on patients over 70 urgent ERCP and, when bile duct stone is diagnosed, EST with stone extraction is justified, too.

[Distribution of ABO groups in patients undergoing heart surgery]

The authors examined retrospectively the AB0 blood groups of 3982 patients who underwent cardiac surgery. There were 3392 cases of acquired heart disease, 590 congenital heart disease. They found significant difference in the total patients blood groups distribution in contrast to the control group. Further significant differences were found in the following cases: 1. total male patients, 2. acquired heart disease (both males and females), 3. isolated aortic valve disease (both males and females), 4. ischaemic heart disease (only males). In regard to the total patients group, their findings suggest significant difference between the males and females blood group distribution. This observation was peculiar to the acquired heart diseases only. They conclude that there is a positive correlation between AB0 blood groups and certain cardiac diseases, most notably, ischaemic heart disease in male patients.

Carotid sinus hypersensitivity abolished by aminophylline

A 56-year-old patient with syncope due to carotid sinus hypersensitivity is presented. Carotid massage-induced sinus arrest was completely abolished by intravenous aminophylline.

[Pathogenic role of a pacemaker in occult infection]

A case of seronegative pacemaker lead infection is presented. The diagnosis based on patient history and echocardiography was proved by removing the infected leads from the beating heart through surgery.

[Rhabdomyoma of unusual manifestation]

According to our knowledge in adult pericardial effusion has never been reported to be present in cases of cardiac rhabdomyoma. We present the history of an adult patient with pericardial effusion due to cardiac rhabdomyoma.

Pericardial effusion as a result of cardiac rhabdomyoma

A 34-yr-old patient is presented who suffered from chronic pericardial effusion. Surgical exposure revealed a right atrial rhabdomyoma.

[Combined coronary artery and heart valve surgery at the Clinic for Cardiovascular Surgery (1979-1990)]

As a result of increasing mean age of patient undergoing open heart surgery more and more combined valve and coronary surgery cases are performed. The operative risk of combined procedure is higher than that of valve replacement or coronary bypass grafting alone. In case of aortic valve disease the operation reduces the workload of the left ventricle thus decreasing the oxygen demand of the myocardium. In pure mitral valve stenosis as a consequence of valve replacement the left ventricular preload increases and coexisting coronary artery disease is of greater importance than in the other case. Since 1979 until the end of 1990 there were 146 combined operations performed in the Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest. The operative results and theoretical considerations are discussed.

[Coronary surgery at the Cardiovascular Surgical Clinic (1976-1990)]

In the Cardiovascular Surgical Clinic of the Semmelweis Medical University of Budapest the first coronary artery bypass grafting (CABG) procedure was performed in 1975. Since that time coronary artery surgery has become a routine everyday practice representing more than half of the total workload of adult cardiac surgery. The analysis of 1347 operations performed between 1976-1990 on patients with coronary heart disease showed the followings: the first few years--so called learning curve of CABG operations is characterised by high mortality. With passing time the number of cases performed each year increased rapidly and the surgical technique has improved too. At the same time the operative mortality figures showed decreasing tendency--it was 2.1% for the last 609 cases. All observed parameters showed some progress: in 1990 the average number of grafts per patient was 3.09, internal mammary artery usage 15 percent and the mean aortic cross clamp time per anastomosis 24.5 minutes. Complete myocardial revascularisation is the key point of coronary artery surgery. In order to achieve this target in all operated cases further technical improvement is necessary.

[Development and results of valve replacement surgery at the Városmajor Clinic 1976-1990 (retorospective clinical analysis)]

In Hungary valve replacement is still a major indication for heart surgery in adults. In the Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest from 1976 to 1990 2435 patients were operated for valve disease. Majority of the cases had single (aortic n = 856, mitral n = 912) or double (aortic + mitral n = 513) valve replacement. Over this 15 years period there have been many alterations in patients characteristics and surgical technique as well. In spite of the increasing mean age of patients the operative mortality has decreased (in the last 5 years period it was 2.7%, 5.5% and 7.9% in the three groups respectively). At the same time the number of patients requiring valve re-replacement or combined valve + coronary procedure has increased. The use of bioprosthetic valves has fallen below 10 percent from the 60--80 percent observed between 1976--1980. The analysis showes excellent surgical results in the field of valve replacement in Hungary.

Phenelzine vs atenolol in social phobia. A placebo-controlled comparison

Seventy-four patients who met DSM-III criteria for social phobia completed 8 weeks of double-blind, randomly assigned treatment with the monoamine oxidase inhibitor phenelzine sulfate, the cardioselective beta-adrenergic blocker atenolol, or placebo. The overall response rates were 64% for phenelzine, 30% for atenolol, and 23% for placebo. Phenelzine was widely superior to both atenolol and placebo on independent rater analyses and, to a lesser extent, on self-report, with no significant differences between atenolol and placebo. At the end of 16 weeks, phenelzine was still significantly superior to placebo, while atenolol showed an intermediate response that did not differ significantly from either of the other treatments. Patients with generalized social phobia constituted 76% of the sample, and they were preferentially responsive to phenelzine. The small size of the discrete social phobic sample precluded separate outcome analyses for this subtype. Overall, the findings support the responsivity of social phobia to monoamine oxidase inhibitors.

[The place and role of coronary endarterectomy in the management of ischemic heart disease]

Coronary endarterectomy is one of the oldest operation performed on the coronary arteries. In the case of multivessel coronary artery disease it is an alternative method to achieve complete myocardial revascularisation however it increases both perioperative infarction rate and mortality. Sometimes it is undoubtedly the only chance of the patient apart from heart transplantation. Since 1983 when the first coronary endarterectomy was performed in the Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest, until the end of 1990 the procedure has been used in 97 patients on 119 coronary artery segments. A new surgical technique of coronary endarterectomy is described, a detailed analysis of the cases is presented and the results are discussed.

[Development of Hungarian heart surgery, its results and current state in the light of the 40-year activity of the "Városmajor Clinic". Review of 40 years of surgery in Hungary, analysis of mortality data]

Forty years have passed since the first heart surgical department was founded in Hungary. In the University Hospital (present name: Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest) the Hungarian "pioneers" had produced internationally respected results in the mid-fiftieth with the operation of closed mitral commissurotomy. However the technique of cardiopulmonary bypass was first introduced into the clinical practice quite early, it has not become a routine everyday procedure until the late seventies. Over the last 15 years period the number of open heart surgical cases has increased permanently, and the operative mortality decreased at the same time. The analysis of 4743 cases performed between 1976 and 1990 showed improving results both in the field of valve replacement and coronary artery surgery and the recent operative mortality figures (3-5% in different groups) are comparable to other European centers.

Clinical and pathological effects of the dermonecrotic toxin of Bordetella bronchiseptica and Pasteurella multocida in specific-pathogen-free piglets

The role of dermonecrotic toxin (DNT) of Bordetella bronchiseptica and Pasteurella multocida, purified by repeated chromatography in Sephacryl S-200 gel, in the pathogenesis of atrophic rhinitis (AR) of swine was studied bacteriologically, clinically and pathologically. Two-week-old specific pathogen-free (SPF) piglets were parenterally treated with 30 micrograms of DNT 3 times at 2-day interval and 7-week-old piglets were treated with 15 micrograms of DNT twice a week for 5 weeks. In 2- to 3-week-old piglets, both B. bronchiseptica DNT and P. multocida DNT produced nasal turbinate lesions with similar severity, characterized by damage of the cilia, epithelial metaplasia, intensive proliferation of osteoblasts, regressive changes, and diffuse osteocytic osteolysis. In 7- to 12-week-old piglets, treatment with B. bronchiseptica DNT failed to produce progressive changes in the nasal turbinates. Histopathological examination revealed osteogenic processes and osteoid synthesis besides the proliferation of osteoblasts and mild osteocytic osteolysis. Moreover, severe gross pathological lesions developed in the stomach, liver, kidneys, and lymphoid organs. The piglets' appetite and body weight gain gradually decreased during the DNT treatment and in the last week when the toxic signs appeared. Treatment of 7- to 12-week-old piglets with P. multocida DNT resulted in progressive AR. Histopathologically, diffuse osteocytic osteolysis was observed in the nasal turbinates. Neither clinical signs nor pathological lesions of the visceral organs developed in these piglets. The authors emphasize that the DNT of B. bronchiseptica basically differs from that of P. multocida in biological properties, though there are certain similarities between the DNTs.

Signs of central nervous system dysfunction in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) has been linked to altered neurological function following head trauma, encephalitis, abnormal birth events, and Gilles de la Tourette's syndrome. Abnormalities in computed tomographic scans, electroencephalograms, positron emission tomographic scans, and evoked potentials have been described in this disorder, but are neither consistent nor pathognomonic of OCD. Neurological soft signs are nonlocalizing signs of deviant performance on a motor or sensory test where no other sign of a neurological lesion is present. We studied 41 medication-free patients with OCD who met DSM-III-R criteria, as well as 20 normal controls, matched for age, sex, and handedness, on 20 individual tasks that involved fine motor coordination, involuntary movements, and sensory and visuospatial function. There were significantly more signs of central nervous system dysfunction in the OCD group, as shown by abnormalities in fine motor coordination, involuntary and mirror movements, and visuospatial function. An excess of findings on the left side of the body and abnormalities of cube drawing may suggest right hemispheric dysfunction in a subgroup of patients with OCD. Soft signs correlated with a severity of obsessions. There was also a correlation between abnormalities in visual memory and recognition on neuropsychological testing and total soft signs. These findings provided additional evidence for a neurological deficit in some patients with OCD. However, further comparisons with other psychiatric populations are needed to determine whether these findings are unique to OCD or are a property of other psychiatric disorders as well.

Fluoxetine treatment of obsessive-compulsive disorder: an open clinical trial

The selective serotonin reuptake blocker fluoxetine was administered to 49 patients with obsessive-compulsive disorder in a 12-week open clinical trial. A minimum adequate trial of at least 8 weeks of treatment was completed by 39 patients. Response rates were 62% (24/39) of adequately treated patients and 49% (24/49) of the whole sample. These uncontrolled findings suggest that fluoxetine is of significant benefit for a substantial proportion of obsessive-compulsive disorder patients. However, controlled trials comparing fluoxetine with placebo and other active agents are needed to confirm this, as are studies aimed to delineate fluoxetine's full dose range, optimal length of treatment and relapse rate following discontinuation.

Effects of clonidine on alprazolam discontinuation in panic patients: a pilot study

Effects of adjunctive clonidine (0.15 to 0.7 mg/day) on symptoms experienced during and for 4 weeks after gradual alprazolam discontinuation were observed in panic disorder patients after 6 weeks of successful treatment. Twelve of 14 entered patients were considered to have had a sufficient period of discontinuation (2 weeks) and clonidine administration (1 week) for effects to be assessed adequately. Nine of these 12 patients reached zero dose of alprazolam in 3 to 4 weeks. However, 10 of 12 patients experienced new withdrawal symptoms and 11 of 12 experienced recurrent panic attacks during tapering. Although a greater proportion of patients were successfully discontinued in a shorter time than in a previous nonclonidine trial, clonidine did not appear to have a specific effect on relapse or withdrawal. A placebo-controlled trial is needed to discriminate between possible contributions of clonidine and other factors (e.g., physician attitude, placebo effect of pill taking) to this improved outcome.

Pharmacotherapy of social phobia: an interim report of a placebo-controlled comparison of phenelzine and atenolol

Forty-one patients meeting DSM-III criteria for social phobia completed a randomized comparative trial of the monoamine oxidase inhibitor phenelzine, the cardioselective beta-adrenergic blocker atenolol, and placebo. No significant differences were seen after 4 weeks of treatment in this preliminary trial. At the end of 8 weeks, however, phenelzine demonstrated greater efficacy than atenolol or placebo on dimensional ratings of overall severity of social phobia. No atenolol-placebo differences were observed. The authors shall present maintenance and discontinuation findings in a final report. Phenelzine may act in patients with social phobia by directly reducing interpersonal hypersensitivity.